Neutrófilos en el diagnóstico de infarto del miocardio tipo 4a / Neutrophils in the Diagnosis of Type 4 Myocardial Infarction

Introducción: El infarto del miocardio tipo 4a es una complicación del intervencionismo coronario percutáneo que incrementa el estado inflamatorio de los pacientes. Objetivo: Evaluar el valor diagnóstico del conteo absoluto de neutrófilos en la aparición de infarto del miocardio tipo 4a. Métodos: Se realizó una cohorte prospectiva en el Hospital Hermanos Ameijeiras. El universo estuvo constituido por 412 pacientes a los que se les realizó intervencionismo coronario percutáneo en el período comprendido de noviembre de 2018 a enero de 2021, la muestra fue de 232 pacientes. Se definieron variables clínicas, anatómicas, e inflamatorias. Resultados: Existieron diferencias significativas entre los pacientes con infarto tipo 4a y los que no tuvieron esta complicación según las variables clínicas: edad, índice de masa corporal, diabetes mellitus, enfermedad renal crónica y disfunción sistólica ventricular. La elevación del conteo absoluto de neutrófilos posterior al proceder con un área bajo la curva de 0,947 tuvo buena capacidad de discriminación de esta complicación (p = 0,000). En el diagnóstico de infarto periproceder el conteo absoluto de neutrófilos fue 7,35 posterior al proceder, tuvo una sensibilidad de 91,3 por ciento una especificidad de 96,2 por ciento. Conclusiones: Los neutrófilos fueron sensibles y específicos para el diagnóstico de infarto del miocardio tipo 4a(AU)

Introduction: Type 4 myocardial infarction is a complication of percutaneous coronary intervention that increases the inflammatory state of patients. Objective: To evaluate the diagnostic value of the absolute neutrophil count in the occurrence of type 4 myocardial infarction. Methods: A prospective cohort was carried out at Hermanos Ameijeiras Clinical Surgical Hospital. The universe consisted of 412 patients who underwent percutaneous coronary intervention from November 2018 to January 2021, two hundred thirty-two (232) patients form the sample. Clinical, anatomical and inflammatory variables were defined. Results: There were significant differences between patients with type 4 infarction and those who did not have this complication according to the clinical variables such as age, body mass index, diabetes mellitus, chronic kidney disease and ventricular systolic dysfunction. The subsequent elevation of the absolute neutrophil count when proceeding with an area under the 0.947 curve had good ability to discriminate this complication (p = 0.000). In the diagnosis of periprocedural infarction, the absolute neutrophil count was ≥ 7.35 after the procedure, it had 91.3percent sensitivity and 96.2percent specificity. Conclusions: Neutrophils were sensitive and specific for the diagnosis of type 4 myocardial infarction(AU)

Efficacy of intravascular ultrasound versus coronary angiographic guided drug-eluting stent implantation in the treatment of left main coronary artery disease: a meta-analysis / 中华心血管病杂志

Objective: To compare the efficacy of intravascular ultrasound (IVUS) and coronary angiography guided drug eluting stent (DES) implantation for the treatment of left main coronary artery (LMCA) lesions. Methods: Randomized controlled trials (RCT) and observational studies, which compared IVUS with coronary angiography guided DES implantation for the treatment of LMCA lesions published before August 2021 were searched in PubMed, Embase and Cochrane Library databases. Baseline data, interventional procedures and endpoint events of each study were collected. The primary endpoint was major cardiovascular adverse events (MACE), and the secondary endpoints were all-cause death, cardiac death, myocardial infarction (MI), target lesion revascularization (TLR) and target vessel revascularization (TVR). The Newcastle-Ottawa Scale (NOS) and the Cochrane Collaboration Risk of Bias tool were used to evaluate the quality of the included studies. Results: Nine studies were included, including 3 RCT and 6 observational studies, with a total of 5 527 cases of LMCA. All the 6 observational studies had NOS scores≥6, and the 3 RCT had a low risk of overall bias. The results of meta-analysis showed that compared with coronary angiography guided group, MACE rate (OR=0.55, 95%CI 0.47-0.66, P<0.001), all-cause death (OR=0.56, 95%CI 0.43-0.74, P<0.001), cardiac death (OR=0.43, 95%CI 0.30-0.61, P<0.001), MI (OR=0.64, 95%CI 0.52-0.79, P<0.001), TLR (OR=0.49, 95%CI 0.28-0.86, P=0.013) and TVR (OR=0.77, 95%CI 0.60-0.98, P=0.037) were all significantly lower in the IVUS guided group. Conclusions: Compared with angiography guided, IVUS guided PCI with DES implantation in LMCA lesions could significantly reduce the risk of MACE, death, MI, TLR and TVR. IVUS is thus superior to coronary angiography for guiding PCI treatment among patients with LMCA.

Anti-inflammatory Therapy Progress in Major Adverse Cardiac Events after PCI: Chinese and Western Medicine / 中国结合医学杂志

Acute coronary syndrome (ACS) is one of the leading causes of death in cardiovascular disease. Percutaneous coronary intervention (PCI) is an important method for the treatment of coronary heart disease (CHD), and it has greatly reduced the mortality of ACS patients since its application. However, a series of new problems may occur after PCI, such as in-stent restenosis, no-reflow phenomenon, in-stent neoatherosclerosis, late stent thrombosis, myocardial ischemia-reperfusion injury, and malignant ventricular arrhythmias, which result in the occurrence of major adverse cardiac events (MACE) that seriously reduce the postoperative benefit for patients. The inflammatory response is a key mechanism of MACE after PCI. Therefore, examining effective anti-inflammatory therapies after PCI in patients with ACS is a current research focus to reduce the incidence of MACE. The pharmacological mechanism and clinical efficacy of routine Western medicine treatment for the anti-inflammatory treatment of CHD have been verified. Many Chinese medicine (CM) preparations have been widely used in the treatment of CHD. Basic and clinical studies showed that effectiveness of the combination of CM and Western medicine treatments in reducing incidence of MACE after PCI was better than Western medicine treatment alone. The current paper reviewed the potential mechanism of the inflammatory response and occurrence of MACE after PCI in patients with ACS and the research progress of combined Chinese and Western medicine treatments in reducing incidence of MACE. The results provide a theoretical basis for further research and clinical treatment.

Effect of complete percutaneous revascularization on improving long-term outcomes of patients with chronic total occlusion and multi-vessel disease / 中华医学杂志(英文版)

BACKGROUND@#Limited data are available on the comparison of clinical outcomes of complete vs. incomplete percutaneous coronary intervention (PCI) for patients with chronic total occlusion (CTO) and multi-vessel disease (MVD). The study aimed to compare their clinical outcomes.@*METHODS@#A total of 558 patients with CTO and MVD were divided into the optimal medical treatment (OMT) group ( n = 86), incomplete PCI group ( n = 327), and complete PCI group ( n = 145). Propensity score matching (PSM) was performed between the complete and incomplete PCI groups as sensitivity analysis. The primary outcome was defined as the occurrence of major adverse cardiovascular events (MACEs), and unstable angina was defined as the secondary outcome.@*RESULTS@#At a median follow-up of 21 months, there were statistical differences among the OMT, incomplete PCI, and complete PCI groups in the rates of MACEs (43.0% [37/86] vs. 30.6% [100/327] vs. 20.0% [29/145], respectively, P = 0.016) and unstable angina (24.4% [21/86] vs. 19.3% [63/327] vs. 10.3% [15/145], respectively, P = 0.010). Complete PCI was associated with lower MACE compared with OMT (adjusted hazard ratio [HR] = 2.00; 95% confidence interval [CI] = 1.23-3.27; P = 0.005) or incomplete PCI (adjusted HR = 1.58; 95% CI = 1.04-2.39; P = 0.031). Sensitivity analysis of PSM showed similar results to the above on the rates of MACEs between complete PCI and incomplete PCI groups (20.5% [25/122] vs. 32.6% [62/190], respectively; adjusted HR = 0.55; 95% CI = 0.32-0.96; P = 0.035) and unstable angina (10.7% [13/122] vs. 20.5% [39/190], respectively; adjusted HR = 0.48; 95% CI = 0.24-0.99; P = 0.046).@*CONCLUSIONS@#For treatment of CTO and MVD, complete PCI reduced the long-term risk of MACEs and unstable angina, as compared with incomplete PCI and OMT. Complete PCI in both CTO and non-CTO lesions can potentially improve the prognosis of patients with CTO and MVD.

Application of SYNTAX and its Derivative Scores in the Selection of Revascularization Strategies for Complex Coronary Heart Disease / 中国医学科学杂志(英文版)

Complex coronary heart disease (CHD) has become a hot spot in medicine due to its complex coronary anatomy, variable clinical factors, difficult hemodynamic reconstruction, and limited effect of conservative drug treatment. Identifying complex CHD and selecting optimal treatment methods have become more scientific as revascularization technology has improved, and coronary risk stratification scores have been introduced. SYNTAX and its derivative scores are decision-making tools that quantitatively describe the characteristics of coronary lesions in patients based on their complexity and severity. The SYNTAX and its derivative scores could assist clinicians in rationalizing the selection of hemodynamic reconstruction treatment strategies, and have demon-strated outstanding value in evaluating the prognosis of patients with complex CHD undergoing revascularization treatment. The authors in this article summary the practical application of SYNTAX and its derivative scores in complex CHD in order to deepen the understanding of the relationship between the choice of different revascularization strategies and SYNTAX and its derived scores in complex CHD and provide a further reference for clinical treatment of complex CHD.

Multimorbidity in elderly patients with acute coronary syndrome: insights from BleeMACS registry / 中华心血管病杂志

Objective: To assess the prevalence, pattern and outcome of multimorbidity in elderly patients with acute coronary syndrome (ACS). Methods: Secondary analysis was performed based on the data from the BleeMACS registry, which was conducted between 2003 and 2014. We stratified elderly patients (≥65 years) according to their multimorbidity. Multimorbidity was defined as two or more chronic diseases in the same individual. Kaplan-Meier methods were used to estimate 1 year event rates for each endpoint, and comparisons between the study groups were performed using the log-rank test. The primary endpoint was net adverse clinical events (NACE), which is a composite of all-cause mortality, myocardial infarction, or bleeding. Results: Of 7 120 evaluable patients, 6 391 (89.8%) were with morbidity (1 594 with 1, 2 156 with 2, and 2 641 with ≥3 morbidity). Patients with morbidity were older, percent of female sex and non-ST-elevation acute coronary syndromes and implantation rate with drug-eluting stents and blood creatine level were higher compared to patients without morbidity. Compared with the patients without morbidity, the proportion of participants with oral anticoagulant increased in proportion to increased number of morbidities (5.8% vs. 6.4% with 1 morbidity, 7.3% with 2 morbidities, 9.0% with ≥3 morbidities, P trend<0.01) and the proportion of participants with clopidogrel prescription decreased in proportion to increased number of morbidity (91.9% vs. 89.7% with 1 morbidity, 87.9% with 2 morbidities, 88.6% with ≥3 morbidities, P trend = 0.01). During 1 year follow-up, compared with those with no morbidity, the hazard ratio (HR) and 95% confidence interval (CI) of risk of NACE for those with 1, 2, and ≥ 3 morbidities was 1.18 (0.86-1.64), 1.49 (1.10-2.02), and 2.74 (2.06-3.66), respectively (P < 0.01). Multimorbidity was not associated with an increased risk of bleeding of various organs (P>0.05). Conclusion: Multimorbidity is common in elderly patients with ACS. These patients might benefit from coordinated and integrated multimorbidity management by multidisciplinary teams.

Meta-analysis on efficacy of PCI treatment or conservative treatment among patients with chronic total occlusions / 中华心血管病杂志

Objective: To compare the efficacy between percutaneous coronary intervention (PCI) and conservative medication treatment in chronic total occlusions (CTO) patients. Methods: It was a meta-analysis.Articles on drug therapy and PCI for complete coronary artery occlusion were retrieved from Pubmed, Embase and Web of Science databases. The search time was from the database construction to May 10, 2020, and the following search criteria were used for the search "chronic total occlusion" "percutaneous coronary intervention" and "medical therapy". References from searched literatures were also searched to identify more eligible studies. Randomized controlled trials (RCT) and cohort studies comparing efficacy of PCI versus oral medication as well as medication as initial therapy option for CTO patients with single or multiple lesions were included. The primary endpoints included all-cause death, cardiac death, recurrent myocardial infarction, re-revascularization, major adverse cardiac events (MACE) and stroke. Data were analyzed with ReviewManager5.3.0 software. Pooled effect size RR and 95%CI were calculated by randomization effect model. Heterogeneity was evaluated by I2. Bege test was used to evaluate publication bias. Subgroup analyses were performed for RCT and cohort studies. Results: A total of 1 079 articles were retrieved and 16 studies (RCT=4, cohort study=12) were included with 12 223 patients. Fourteen publications (RCT=4, cohort study=10) reported all-cause death post PCI and/or drug therapy. Results showed that risk of all-cause death was significantly lower in PCI group than in drug therapy group (RR=0.45,95%CI 0.39-0.53,P<0.001);subgroup analysis showed that risk of all-cause death was significantly lower in PCI group than in drug therapy group from cohort studies (RR=0.44,95%CI 0.38-0.52,P<0.001),but comparable in RCT (P=0.27). Thirteen studies (RCT=3, cohort study=10) reported cardiac death post PCI and/or drug therapy. Results showed that risk of cardiac death was significantly lower in PCI group than in drug therapy group (RR=0.44,95%CI 0.35-0.55,P<0.001);subgroup analysis showed that risk of cardiac death was significantly lower in PCI group than in drug therapy group in cohort studies (RR=0.43,95%CI 0.34-0.54,P<0.001),but not in RCT (P=0.25). Fourteen publications (RCT=4, cohort study=10) reported recurrent myocardial infarction post PCI and/or drug therapy. Results showed that risk of recurrent myocardial infarction was significantly lower in PCI group than in drug therapy group (RR=0.62,95%CI 0.44-0.88,P=0.007);subgroup analysis showed that risk of recurrent myocardial infarction was significantly lower in PCI group than in drug therapy group from cohort studies (RR=0.56,95%CI 0.40-0.78,P=0.000 5),but comparable in RCT (P=0.17). Fourteen publications (RCT=4, cohort study=10) reported re-revascularization post PCI and/or drug therapy. Results showed that risk of re-revascularization was comparable between PCI group and drug therapy group (P=0.91);subgroup analysis showed that risk of re-revascularization was comparable between PCI group and drug therapy group both in cohort study and RCT (P=0.60 and 0.41, respectively). Eleven publications (RCT=3, cohort study=8) reported MACE post PCI and/or drug therapy. Results showed that risk of MACE was significantly lower in PCI group than in drug therapy group (RR=0.74,95%CI 0.59-0.93,P=0.03);subgroup analysis showed that risk of MACE was significantly lower in PCI group than in drug therapy group in cohort studies (RR=0.72,95%CI 0.56-0.93,P=0.01), but not in RCT (P=0.8). Six publications (RCT=2, cohort study=4) reported stroke post PCI and/or drug therapy. Results showed that risk of stroke was comparable between PCI and drug therapy groups (RR=0.62,95%CI 0.32-1.20, P=0.15);subgroup analysis showed that risk of stroke was comparable between PCI and drug therapy groups both in cohort studies and RCT (P=0.48 and 0.32, respectively). Conclusion: Compared with oral drug therapy, PCI may have better efficacy for CTO patients based on results from this cohort study.

Índice neutrófilo linfocitario en la predicción del infarto del miocardio tipo 4a / Lymphocyte neutrophilic index in the prediction of type 4 myocardial infarction

Introducción: El infarto del miocardio tipo 4a es una complicación del intervencionismo coronario percutáneo, que se asocia a un proceso inflamatorio. El índice neutrófilo linfocitario, como marcador de inflamación, pudiera incluirse en su estratificación del riesgo. Objetivos: Evaluar la sensibilidad, especificidad, los valores predictivos y la variación del índice neutrófilo linfocitario en la predicción del infarto del miocardio tipo 4a. Métodos: Investigación de cohorte prospectiva, en 184 pacientes a los que se les realizó intervencionismo coronario percutáneo. Resultados: Para un valor mayor e igual a 2,74, el índice mostró una sensibilidad de 72,0 por ciento, una especificidad de 74,8 por ciento un valor predictivo negativo de 94,4 por ciento en la predicción de infarto tipo 4a. La variación del índice fue predictor independiente de la complicación p < 0,001. Conclusiones: El índice neutrófilo linfocitario tiene alta sensibilidad, especificidad y valor predictivo negativo en la predicción del infarto tipo 4a. Su elevación a las seis horas del proceder es un predictor independiente para dicha complicación(AU)

Introduction: Type 4a myocardial infarction is a complication of percutaneous coronary intervention, which is associated with an inflammatory process. The lymphocyte neutrophilic index, as a marker of inflammation, could be included in your risk stratification. Objectives: To assess the sensitivity, specificity, predictive values and the variation of the lymphocyte neutrophilic index in the prediction of type 4a myocardial infarction. Methods: A prospective cohort investigation was carried in 184 patients who underwent percutaneous coronary intervention. Results: For a value higher than and equal to 2.74, the index showed 72.0 percent, sensitivity, 74.8 percent specificity and 94.4 percent negative predictive value in the prediction of type 4a infarction. The variation of the index was an independent predictor of the complication p < 0.001. Conclusions: The lymphocyte neutrophil index has high sensitivity, specificity and negative predictive value in the prediction of type 4a infarction. Its elevation six hours after the procedure is an independent predictor for this complication(AU)

Beyond Atherothrombotic Disease in Acute Coronary Syndrome

Abstract Half of the global population over 20 years of age will be affected by cardiovascular disease. Cardiovascular events in young people is challenging. Spontaneous coronary artery dissection is a non-traumatic and non-iatrogenic separation of the coronary arterial wall and is an uncommon and underdiagnosed cause of acute myocardial infarction predominately found in young women. Medical management has been more widely accepted, with percutaneous and surgery treatment reserved for precise indications. Optimal control of individual risk factors is essential in order to avoid recurrences.

Recurrencia clínica en pacientes con puentes secuenciales en cirugía de revascularización coronaria / Clinical recurrence in patients with sequential bridges in coronary artery bypass grafting

Resumen Objetivo: Comparar las tasas de recurrencia de revascularización coronaria (cirugía o intervención coronaria percutánea), nuevo evento isquémico o muerte en pacientes con puentes secuenciales y con puentes simples. Método: Cohortes ambispectivas de pacientes sometidos a cirugía de revascularización coronaria secuencial (n = 111) o simple (n = 145) entre el 1 de enero de 2013 y el 31 de diciembre de 2017. Pacientes mayores de 18 años en un primer procedimiento de revascularización, con circulación extracorpórea. Para el seguimiento se realizó revisión del expediente o comunicación telefónica hasta el 9 de febrero de 2019. Se investigaron los siguientes desenlaces: reintervención por isquemia coronaria, nuevo evento isquémico documentado o muerte atribuida a cardiopatía isquémica; también se obtuvieron curvas de sobrevida. Resultados: La proporción de recurrencia según la técnica quirúrgica no fue estadísticamente diferente: secuencial 6.5% (intervalo de confianza del 95% [IC95%]: 2.6-12.6%) contra simple 4.8% (IC95%: 2-9.7%; p = 0.60; análisis bayesiano BF10 = 0.37; evidencia moderada a no diferencia), todos por nuevo evento isquémico y un fallecimiento por grupo. No hubo diferencias en el tiempo de seguimiento: secuencial 59 meses (IC95%: 56-62) y simple 66 meses (IC95%: 64-68). No encontramos diferencia en las tasas de incidencia de recurrencia: secuencial 1.99 eventos/103 meses-paciente contra simple 1.47 (hazard ratio: 1.34; IC95%: 0.47-3.8; p = 0.58). El tiempo promedio de pinzamiento y de circulación extracorpórea por puente fue menor en el grupo de puentes combinados (41.44 minutos de circulación extracorpórea y 24.69 minutos de pinzamiento/puente) que en el de puentes simples (43 minutos en circulación extracorpórea y 26.4 minutos de pinzamiento/puente) cuando se ajusta al promedio de puentes colocados (simples 2.7 y secuencial 3.25; p < 0.001); sin embargo, no se encontró significancia estadística (p = 0.7). Conclusión: Ambos procedimientos tuvieron una baja incidencia de recurrencia de eventos clínicos, sin diferencias entre las técnicas quirúrgicas.

Abstract Objective: To compare the recurrence rates of revascularization (redo CABG or PCI), new ischemic event or death in patients with simple grafts and patients with sequential grafts. Method: Study design is an ambispective cohort of patients that underwent CABG by sequential grafting (n = 111) or simple grafting (n = 145) between January 1st, 2013 and December 31st, 2017. Patients had to be 18 years old at the time of surgery, undergoing their first on-pump CABG. The clinical record of every patient was carefully reviewed and patients who had incomplete follow-up in external consultation were contacted by telephone in order to obtain data about ischemia related reintervention (CABG or PCI), new documented ischemic event or death caused by coronary artery disease, Kaplan-Meier estimators were calculated. Results: The proportion of recurrence depending on technique was not statistically different: sequential (6.5% [CI95% 2.6-12.6%] versus simple 4.8% [CI95% 2-9.7%], p = 0.60, Bayesian analysis BF10 = 0.37; moderate evidence to no difference), each one related to new ischemic event and one death per group. There were no differences in follow-up time (sequential 59m [CI95% 56-62] simple 66m [CI95% 64-68]). No difference was found regarding recurrence incidence rates; sequential 1.99 events x 103 months-patient, versus simple 1.47 (HR=1.34; CI95% 0.47-3.8, p = 0.58). Pump and cross-clamping times were lower for sequential technique (41.44 min; 24.69 min respectively) versus simple technique (43 min; 26.4 min respectively) with a p = 0.7 after adjusting to mean grafts per surgery (2.7 simple; 3.25 sequential, p < 0.001). Conclusions: Both techniques had a low incidence of clinical recurrence, without significant differences between procedures.

Revascularización coronaria híbrida: un punto de encuentro entre cardiólogos intervencionistas y cirujanos cardíacos / Hybrid coronary revascularization: a meeting point between interventional cardiologists and cardiac surgeons

Resumen: La revascularización coronaria híbrida busca combinar el beneficio de las técnicas quirúrgicas y percutáneas para un manejo óptimo de pacientes seleccionados con enfermedad coronaria obstructiva multivaso. Esto permite asociar el beneficio del puente de arteria mamaria interna izquierda a la arteria descendente anterior (ADA) y combinarlo con el implante de stents en lesiones no-ADA. El objetivo de este trabajo es hacer una revisión de la literatura disponible con énfasis en sus resultados clínicos comparados con la estrategia convencional.

Abstract: Hybrid coronary revascularization seeks to combine the benefit of surgical and percutaneous techniques for optimal management of selected patients with multivessel coronary artery disease. This allows combining the benefit of the left internal mammary artery bypass to the anterior descending artery (LAD) and stent deployment in non-LAD lesions. The objective of this manuscript is to review the available literature with emphasis on its clinical results compared to the conventional strategy.

Guía práctica interinstitucional para el tratamiento del infarto agudo de miocardio / Interinstitutional clinical practice guidelines for the treatment of acute myocardial infarction

Resumen Introducción: México tiene la mortalidad más alta a 30 días por infarto agudo de miocardio (IAM), el cual constituye una de las principales causas de mortalidad en el país: 28 % versus 7.5 % del promedio de los países de la Organización para la Cooperación y el Desarrollo Económicos. Objetivo: Establecer las rutas críticas y las estrategias farmacológicas esenciales interinstitucionales para la atención de los pacientes con IAM en México, independientemente de su condición socioeconómica. Método: Se reunió a un grupo de expertos en diagnóstico y tratamiento de IAM, representantes de las principales instituciones públicas de salud de México, así como las sociedades cardiológicas mexicanas, Cruz Roja Mexicana y representantes de la Sociedad Española de Cardiología, con la finalidad de optimizar las estrategias con base en la mejor evidencia existente. Resultados: Se diseñó una guía de práctica clínica interinstitucional para el diagnóstico temprano y tratamiento oportuno del IAM con elevación del segmento ST, siguiendo el horizonte clínico de la enfermedad, con la propuesta de algoritmos que mejoren el pronóstico de los pacientes que acuden por IAM a los servicios de urgencias. Conclusión: Con la presente guía práctica, el grupo de expertos propone universalizar el diagnóstico y tratamiento en el IAM, independientemente de la condición socioeconómica del paciente.

Abstract Introduction: Mexico has the highest 30-day acute myocardial infarction (AMI) mortality rate: 28% versus 7.5% on average for the OECD countries, and it constitutes one of the main causes of mortality in the country. Objective: To establish critical pathways and essential interinstitutional pharmacological strategies for the care of patients with AMI in Mexico, regardless of their socioeconomic status. Method: A group of experts in AMI diagnosis and treatment, representatives of the main public health institutions in Mexico, as well as the Mexican cardiology societies, the Mexican Red Cross and representatives of the Spanish Society of Cardiology, were brought together in order to optimize strategies based on the best existing evidence. Results: An interinstitutional clinical practice guideline was designed for early diagnosis and timely treatment of AMI with ST elevation, following the clinical horizon of the disease, with the proposal of algorithms that improve the prognosis of patients who attend the emergency services due to an AMI. Conclusion: With these clinical practice guidelines, the group of experts proposes to universalize AMI diagnosis and treatment, regardless of patient socioeconomic status.

Translational Approach for Percutaneous Interventions for the Treatment of Cardiac Arrhythmias

Abstract New translational concepts on cellular and tissue substrate of cardiac arrhythmias have been responsible for the development of non-pharmacological interventions, with important achievements compared to the conventional approach with antiarrhythmic drugs. In addition, the increasing knowledge of anatomical and electrophysiological studies, sophisticated mapping methods, special catheters, and controlled clinical trials have favored the progression of ablation of tachyarrhythmias, particularly of ventricular tachyarrhythmias and atrial fibrillation.

Evaluation of pharmacoinvasive strategy versus percutaneous coronary intervention in patients with acute myocardial infarction with ST-segment elevation at the National Institute of Cardiology (PHASE-MX) / Evaluación de la estrategia farmacoinvasiva versus angioplastia coronaria transluminal percutánea primaria en pacientes con infarto agudo de miocardio con elevación del segmento ST en el Instituto Nacional de Cardiología (PHASE-MX)

Abstract Objective: The objective of PHASE-MX registry is to validate the efficacy and safety of the pharmacoinvasive strategy in comparison with percutaneous coronary intervention (PCI) in patients with acute myocardial infarction with ST segment elevation (STEMI) in a metropolitan region of Mexico. The primary outcome will consist of the composite of cardiovascular death, re-infarction, stroke and cardiogenic shock. Methods: The PHASE-MX registry will include a prospective cohort of patients with STEMI who received reperfusion treatment (mechanical of pharmacological) in the first 12 h after the onset of symptoms. The registry is designed to compare the efficacy and safety of primary PCI and pharmacoinvasive strategy. The simple size was calculated in 344 patients divided into two groups, with an estimated loss rate of 10%. Patients included in the PHASE-MX cohort will be followed for up to one year. Conclusion: In Mexico, only 5 out of 10 patients with STEMI have access to reperfusion therapy. Pharmacoinvasive strategy is takes advantage of the accessibility of fibrinolysis and the effectiveness of PCI. The present research protocol aims to provide information that serves as a link between information derived from controlled clinical trials and records derived from real world experience.

Resumen Objetivo: El objetivo del registro PHASE-MX es validar la eficacia y seguridad de la estrategia farmacoinvasiva en comparación con la angioplastia coronaria transluminal percutánea primaria (ACTPp) en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) en una región metropolitana de México. El desenlace primario es el compuesto de muerte cardiovascular, reinfarto, accidente vascular cerebral y choque cardiogénico. Métodos: El registro PHASE-MX es una cohorte prospectiva de pacientes con IAMCEST que recibieron tratamiento de reperfusión (mecánico o farmacológico) en las primeras 12 horas desde el inicio de los síntomas, atendidos en el Instituto Nacional de Cardiología Ignacio Chávez. El análisis estadístico se basa en la no inferioridad de la estrategia farmacoinvasiva en comparación con la ACTPp. Se calcula un tamaño de muestra de 344 pacientes divididos en dos grupos (angioplastia primaria y estrategia farmacoinvasiva), considerada una tasa de pérdidas de 10%. Los pacientes incluidos en la cohorte PHASE-MX se seguirán durante un año. Discusión: En México, sólo 5 de cada 10 pacientes con IAMCEST tienen acceso al tratamiento de reperfusión. La estrategia farmacoinvasiva aprovecha la accesibilidad de la fibrinólisis y la efectividad de la ACTPp, por lo que podría resultar el método de elección en el tratamiento del IAMCEST en la mayoría de los casos. El presente protocolo de investigación pretende aportar información que sirva como enlace entre la información derivada de los estudios clínicos controlados y los registros derivados de la experiencia del mundo real.

Desfechos clínicos de pacientes após uso de terapia fibrinolítica pré-hospitalar: revisão sistemática / Resultados clínicos de pacientes después del uso de terapia fibrinolítica prehospitalaria: revisión sistemática / Clinical outcomes of patients after using prehospital fibrinolytic therapy: a systematic review

Resumo Objetivo: Comparar desfechos clínicos de óbito, reinfarto e Acidente Vascular Encefálico (AVE) em estudos primários que avaliaram o uso da Terapia Fibrinolítica (TF) em relação à Intervenção Coronariana Percutânea Primária (ICPP) para reperfusão miocárdica em pacientes com Infarto Agudo do Miocárdio com supradesnivelamento do segmento ST (IAMCST) no atendimento pré-hospitalar. Método: Revisão sistemática de literatura com busca realizada nas bases de dados CINAHL, MEDLINE, PUBMED, Science Direct, SCOPUS e Web of Science no período de outubro a dezembro de 2017. Foram incluídos Ensaios Clínicos Randomizados, disponíveis na íntegra, em qualquer idioma, sem recorte temporal. A avaliação da elegibilidade foi realizada em duas etapas e aplicada a Escala de Jadad para avaliação metodológica dos estudos encontrados. Resultados: Foram incluídos cinco Ensaios Clínicos Randomizados. A TF pré-hospitalar apresentou taxas de mortalidade em 30 dias após a intervenção semelhantes à ICPP, enquanto que em cinco anos foram encontrados valores menores para a TF. O tratamento instituído em um período menor que duas horas dos sintomas iniciais apresentou associação com a diminuição da mortalidade quando foi utilizada a TF. O reinfarto não-fatal, acidente vascular encefálico e a hemorragia intracraniana foram maiores quando utilizada a TF, enquanto que o choque cardiogênico apresentou menor frequência. Conclusão: A TF foi mais eficaz no tratamento pré-hospitalar para a redução dos óbitos após cinco anos, entretanto, o reinfarto e o AVE ocorreram de forma semelhante na amostra analisada. O fator tempo reduziu os desfechos clínicos, principalmente quando a terapia implementada ocorreu em até duas horas após a ocorrência do IAMCST. Assim, apesar das intervenções terem apresentado desfechos semelhantes, entretanto, a TF pode representar um tratamento viável em locais onde a ICPP não pode ser alcançada em tempo hábil.

Resumen Objetivo: Comparar resultados clínicos de fallecimiento, reinfarto y accidente vascular encefálico (AVE) en estudios primarios que analizaron el uso de la terapia fibrinolítica (TF) respecto a la intervención coronaria percutánea primaria (ICPP) para reperfusión miocárdica en pacientes con infarto agudo de miocardio con supradesnivel del segmento ST (IAMCST) en la atención prehospitalaria. Método: Revisión sistemática de literatura con búsqueda realizada en las bases de datos CINAHL, MEDLINE, PUBMED, Science Direct, SCOPUS y Web of Science en el período de octubre a diciembre de 2017. Se incluyeron ensayos clínicos aleatorizados, con texto completo disponible, en cualquier idioma, sin recorte temporal. El análisis de elegibilidad se realizó en dos etapas y se aplicó la escala de Jadad para una evaluación metodológica de los estudios encontrados. Resultados: Se incluyeron cinco ensayos clínicos aleatorizados. La TF prehospitalaria presentó índices de mortalidad 30 días después de la intervención semejantes a la ICPP, mientras que en cinco años se encontraron valores menores en la TF. El tratamiento aplicado en un período menor a dos horas desde los síntomas iniciales presentó una relación con la reducción de la mortalidad cuando se utilizó la TF. Los reinfartos no fatales, los accidentes vasculares encefálicos y las hemorragias intracerebrales fueron mayores cuando se utilizó la TF, mientras que los choques cardiogénicos presentaron menor frecuencia. Conclusión: La TF fue más eficaz en el tratamiento prehospitalario para reducir los fallecimientos después de cinco años, sin embargo, los reinfartos y los AVE ocurrieron de forma semejante en la muestra analizada. El factor tiempo redujo los resultados clínicos, principalmente cuando la terapia implementada ocurrió hasta dos horas después del episodio del IAMCST. De esta forma, a pesar de que las intervenciones presentaron resultados semejantes, la TF puede representar un tratamiento viable en lugares donde la ICPP no puede realizarse a tiempo.

Abstract Objective: To compare clinical outcomes of death, reinfarction, and stroke in primary studies assessing Fibrinolytic Therapy (FT) use in relation to Primary Percutaneous Coronary Intervention (PPCI) for myocardial reperfusion in patients with ST-Elevation Myocardial Infarction (STEMI) in prehospital care. Method: A systematic literature review conducted in the CINAHL, MEDLINE, PUBMED, Science Direct, SCOPUS, and Web of Science databases from October to December 2017. Randomized Clinical Trials, available in full, in any language, without temporal clipping were included. The eligibility assessment was carried out in two stages and applied to the Jadad Scale for methodological assessment of the studies found. Results: Five Randomized Clinical Trials were included. Prehospital FT presented mortality rates at 30 days after the intervention similar to PPCI, while in five years lower values were found for FT. The treatment instituted in a period of less than two hours of the initial symptoms was associated with the decrease in mortality when FT was used. Non-fatal reinfarction, stroke and intracranial hemorrhage were higher when FT was used, while cardiogenic shock showed lower frequency. Conclusion: FT was more effective in prehospital treatment to reduce deaths after five years, however, reinfarction and stroke occurred similarly in the sample analyzed. The time factor reduced clinical outcomes, especially when the implemented therapy occurred within two hours after the occurrence of STEMI. Thus, although the interventions presented similar outcomes. However, FT may represent a viable treatment in places where PPCI cannot be achieved in a timely manner.

Atención de los síndromes coronarios agudos durante la contingencia sanitaria por brote de SARS-CoV-2 / Care of acute coronary syndromes during the health contingency due to a SARS-CoV-2 outbreak

Resumen Las comunicaciones acumuladas en las últimas semanas dejan claro que no existe un acuerdo para definir la mejor estrategia de tratamiento en los pacientes con un síndrome coronario agudo (SICA). En los pacientes que se presentan con un infarto agudo del miocardio con elevación del segmento ST (IAMCESST) se ha sugerido privilegiar la fibrinólisis (FL) sobre la intervención coronaria percutánea primaria (ICPp), reservando el ICP para los casos de FL fallidar1,2; sin embargo algunas sociedades han mantenido la indicación de la ICPp como el método de repercusión de elecciónr3. En los SICA sin elevación del segmento ST (SICASESST) las recomendaciones son muy similares, favoreciendo el tratamiento medico sobre el intervencionismo coronario percutáneo, en este subgrupo de pacientes1. Varias sociedades consideran el estado de contagio, en particular en los SICASESST, para decidir que estrategia de repercusión seguir3. Anticipando que la curva epidemiológica en México será similar a la observada en la mayoría de los países, recomendamos continuar la atención de los pacientes con SICA, las salas de cateterismo deben mantener su funcionamiento.

Abstract The communications accumulated in the last weeks make it clear that there is no agreement to define the best treatment strategy in patients with acute coronary syndrome (SICA). In patients presenting with an acute myocardial infarction with ST-segment elevation (IAMCESST), it has been suggested to favor fibrinolysis (FL) over primary percutaneous coronary intervention (PCI), reserving ICP for cases of failed FL1,2; however, some societies have maintained the indication of the ICPp as the repercussion method of choice3. In SICAs without ST segment elevation (SICASESST) the recommendations are very similar, favoring medical treatment over percutaneous coronary intervention in this subgroup of patients1. Several companies consider the contagion status, particularly in the SICASESST, to decide which repercussion follow3. Anticipating that the epidemiological curve in Mexico will be similar to that observed in most countries, we recommend continuing the care of patients with SICA, the catheterization rooms must maintain their operation.

Impacto de la contingencia sanitaria por COVID-19 en las estrategias de reperfusión del síndrome coronario agudo / Impact of COVID-19 on reperfusion strategies for acute coronary syndromes

Resumen Las terapias de reperfusión, tales como intervención coronaria y fibrinólisis, son las principales medidas de atención en pacientes con síndromes coronarios agudos. La angioplastia primaria se considera el estándar de oro, sin embargo, en pacientes con infección por coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2), la estrategia de reperfusión más recomendada es la terapia fibrinolítica, debido al menor tiempo requerido para realizarla y menor exposición al agente infeccioso. Esta pandemia representa una problemática de contagio en el personal de salud, ya que los casos van en aumento a nivel mundial, por lo cual es importante conocer las medidas que se deben seguir a fin de evitar la enfermedad por coronavirus 2019 (COVID-19).

Abstract Reperfusion therapy is a measure of care in patients with ST-elevation myocardial infarction (STEMI), which should be performed once we have the diagnosis. Percutaneous coronary intervention is considered the gold standard, however in patients with SARS-CoV-2 infection, the reperfusion strategy is more focused on fibrinolytic therapy due to the shorter time required to perform and less exposure. This pandemic represents a contact problem in health personnel, since cases are increasing worldwide, so it is important to know the measures that must be followed to avoid coronavirus disease (COVID-19).

Risk factors and temporal trends for vascular access-related complications in coronary procedures: evolving from femoral to radial approach / Factores de riesgo y variaciones temporales para complicaciones vasculares asociadas a procedimientos coronarios: evolución de la vía femoral a la radial

Abstract Introduction: Radial access is the gold standard for ST-elevation myocardial infarction; nevertheless, there is scarce information in Mexico. Objectives: The objectives of this study were to describe the differences in radiation exposure, intervention time, fluoroscopy time, complications and temporal trends, and risk factors among radial and femoral access for coronary procedures. Materials and Methods: A total of 493 patients underwent coronary interventions by femoral or radial access. Sociodemographic and procedural data were recorded. A logistic regression model to determine risk factors for complications was performed. Results: The population included 346 men and 147 women, with a median age of 63 years, 159 underwent radial and 334 femoral approaches. Complications occurred in 18 patients (3.6%), 11 in radial and 7 in femoral access, with a higher trend in the first 5 months (n = 14). Vasospasm was the most common (n = 9) complication. Median fluoroscopy time was 12 min for radial and 9 min for femoral groups, with a total radiation dose of 2282 µGm2 and 2848 µGm2, respectively. Temporal trends showed that complications occurred most frequently during the first 6 months of the study. The main predictors for complications were intervention time and one-vessel disease. Conclusions: Radial access had higher frequency of complications than femoral approach and they were more common during the first 6 months. The main risk factor was intervention time longer than 60 min.

Resumen Introducción: El abordaje radial es el de elección para infarto de miocardio con elevación del segmento ST, sin embargo se desconoce información en México. Objetivos: Describir las diferencias en exposición a radiación, tiempo de intervención, tiempo de fluoroscopía, complicaciones y sus variaciones temporales, además de los factores de riesgo entre el abordaje radial y el femoral para procedimientos coronarios. Método: Se incluyeron 493 pacientes que fueron sometidos a estudio angiográfico o intervenciones coronarias por abordaje radial o femoral. Se recabaron datos sociodemográficos, antecedentes y variables del procedimiento. Se realizó un modelo de regresión logística para determinar los factores asociados a complicaciones. Resultados: Se incluyeron 346 hombres y 147 mujeres, con mediana de edad de 63 años. A 159 se les realizó acceso radial y a 334 femoral. Las complicaciones ocurrieron en 18 pacientes (3.65%): 11 en radial y 7 en femoral, teniendo mayor incidencia en los primeros 5 meses (n = 14) y siendo el vasoespasmo el más común (n = 9). La mediana de tiempo de fluoroscopía fue de 12 minutos para el radial y de 9 minutos para el femoral, con una dosis total de radiación de 2,282 µGm2 y 2,848 µGm2, respectivamente. Las tendencias temporales indicaron que las complicaciones fueron más frecuentes durante los primeros 6 meses. Los principales predictores fueron el tiempo de intervención y la enfermedad de 1 vaso. Conclusiones: La vía de acceso radial tuvo más complicaciones que la femoral. Se observaron más complicaciones en los primeros 6 meses del estudio. El principal predictor de complicaciones fue el tiempo de intervención mayor a 60 minutos.

Beneficio económico en la utilización de reserva fraccional de flujo en lesiones coronarias intermedias y su impacto clínico a un año / Economic benefits of fractional flow reserve utilization on intermediate lesions and its clinical impact after one year-follow up

Resumen Antecedentes: La reserva de flujo fraccional (FFR) es una herramienta con evidencia demostrada para guiar las angioplastias coronarias. El reembolso por los sistemas de cobertura de salud es parcial o nulo a pesar de frecuentemente diferir la angioplastia. Nuestro objetivo fue determinar el beneficio económico de la utilización del FFR en la evaluación de lesiones intermedias, y evaluar asimismo puntos finales clínicos en el seguimiento a un año. Métodos: Estudio observacional prospectivo que incluyó una cohorte de pacientes consecutivos con lesiones coronarias intermedias, evaluadas con FFR, entre abril de 2013 y marzo de 2016. Para el análisis económico se evaluaron los recursos específicos utilizados para la realización del procedimiento. Se analizaron puntos finales clínicos (muerte cardiovascular, revascularización de la arteria objetivo e infarto agudo de miocardio) durante la internación y en el seguimiento a un año Resultados: Se incluyeron 222 lesiones en 151 pacientes consecutivos. Se registró FFR positivo en el 26.1% de las lesiones evaluadas. Se estimó que sin la utilización de FFR, 126 pacientes hubieran sido tratados con angioplastia transluminal coronaria y 25 con cirugía de revascularización miocárdica. El costo estimado con la utilización de FFR fue US$ 891,290.08, mientras que sin el mismo hubiera sido de US$ 1,557,352. Esto implicó un ahorro del 43% de los gastos. Se observaron una muerte de origen cardiovascular y dos reinternaciones en el grupo FFR positivo en el seguimiento a un año. Conclusiones: La revascularización de lesiones intermedias guiada por FFR resultó en un beneficio económico al reducir los costos generales sin resultar clínicamente perjudicial.

Abstract Background: Fractional flow reserve (FFR) is a proven technology for guiding percutaneous coronary intervention, but it is not reimbursed despite the fact that it frequently allows to defer revascularization. Our goal was to determine the economic benefit of FFR on intermediate lesions, as well as the clinical endpoints at 1 year follow up. Methods: Observational prospective study that included consecutive patients with intermediate lesions evaluated with FFR between April 2013 and March 2016. For the economic analysis we evaluated the specific resources used during the procedure. Clinical endpoints including cardiovascular death, target lesion revascularization and acute myocardial infarction, were followed up over a one-year period. Results: FFR was performed on 222 lesions in 151 consecutive patients. FFR was positive in 26.1% of the assessed lesions. The estimated total cost using FFR was US$ 891,290.08 while cost estimate without FFR was US$ 1,557,352, meaning 43% in cost savings. There was one cardiovascular death and two readmissions during follow up in the positive FFR group. Conclusions: FFR guided revascularization on intermediate coronary lesions resulted in an economic benefit by reducing overall costs without harming clinical outcomes.